Begly, Phebe rro OF QUEEN
B U9KY
PINE VIEW CEMETERY AND CREMATORIUM,
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
II Funeral Director BA�C-2
Name l Case # :LZ
Date of Cremation
Time Cremation Started � � ►h
Time Cremation Completed
Type of Container _ Lj P0war till _TF f,r* 5
Remarks :
11 SU ►�h
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office:(518)745-4476, Crematorium: (518)745-4477
Autiwrization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate,�remains of:
j'hebe- Ruih
(Name) (SOX)
(street) (CRY) f1 ( ) (spoe)
who died on Z 3 day of p�G raj �� 200
-2-, fsi iA1�oi[,(WdY- W► I Tvty-,/VC4)Yvrk I Z 8i,b
Place) ( )
Name and address of nearest Ong rob"or name of person authorizing cremation:
U1ANdfl M�dIrnrlv#W/I ifIAkN )b,-tI2�
(Name) (ems)
Relatiordilp to the deceaseed h(�
Name of Funeral Home ll 11%16
IMPORTANT:
I represent that to the best of my knowledge,the deceased(hes)or pacemaker,defibrillate,battery,battery pack,power
call,radioactive implant or radioactive device in his or her body.( )
1 certily that I have full power and authorization to arrenge for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and..
save harmless Pine View crematorium from any and ak claims and demands for loss or damages wtdch may be made against them
by reason torcoannectedwkh cremationa if sold remains as directed,whether such claims or demands are or are not whofiy
9 r di Tsl;o�IWjqy-UI;jrP'Vg��O
SA vt!--
(SbnaWr6 and Address of ReWlive or Legal Representative)
Signed on this data:
Disposition of Cremated Remains
1 hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please spedfy
If pulverization of cremated remains Is requested,check here
Revision:January 1,2W9